2014_0321CHECK ONE:
IRRIGATION A DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 9
LOCATION OF SERVICE: 44 ,� l
The backllow prevention assembly detailed below has been tested and maintained as required by TCEQ
re- ulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C2 Reduced Pressure Principle Pressure V acnmi Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Lbt,0 Size 2',
Model Number 8� C Located At G-' fu-g-A-e- Y' �7�,� vet
Serial Number C �S
The above is certified to be true.
Firm Name A,cilo yt h r-e- Rac 'S Certified TO_P66( O C S
Firm Address A hV W 7 lti. M 11,14 C hLC Cat Tester No. jhs6kk Date
Gauge #&L llG�7�
Date last accuracy tested3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Cheek Valve Assembly
Relief Valve
Air Inlet
Check Valve
i Ist�Check
Znd Check
Initial Test
DC- Closed 2 -C
Closed Tight ;k
Opened at
Opened at
+_,_psid
Tight 0
Leaked Z . 2 M
psid
psid
RP -_ Dsid
Leaked C
Did not Open 0
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight D
tasid
�>zsid
RP sid
The above is certified to be true.
Firm Name A,cilo yt h r-e- Rac 'S Certified TO_P66( O C S
Firm Address A hV W 7 lti. M 11,14 C hLC Cat Tester No. jhs6kk Date
Gauge #&L llG�7�
Date last accuracy tested3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy